Support Servicesexitassessment

Support servicesexitAssessment

Calgary HMIS

This form is to be completed upon a client’s exit from a program.

Program-Level information

Date of Exit Interview (mm/dd/yyyy):
Program name: / Program exit date:
Case worker name: / Case worker phone number:

Basic INFORMATION

Last name: / First name: / Middle name: / Prefix:
Suffix:
Also known as (A.K.A.)/ Nickname(s): / Date of birth: / Age:
What is your gender?
Female Male Transgender Don’t know Declined to answer

Exit Information (to be input into Entry/Exit tab in the HMIS)

Why is the client leaving the program?
Completed program Criminal activity/violence Death Disagreement with rules/persons Left for housing opportunity before completing program Needs could not be met Non-compliance with program Non-payment of rent Reached maximum time allowed Referred to another program Unknown/disappeared Other ______
What is the client’s destination?
Outside (rough sleeping, camping, vehicle) Dwelling unfit for human habitation Emergency shelter Addictions treatment facility Staying with family or friends (couch surfing) Correctional facility Hospital/medical facility Child Intervention Services placement Hotel/motel Transitional housing Long-term housing with supports Renting – Subsidized Renting – Unsubsidized
Family home Own home Other ______Declined to answer Caseworker doesn’t know (Client unknown/disappeared)
Can Exit Interview be completed by client? Yes (please fill out interview questions below)
No (known answers below to be filled in only)

Citizenship & Migrant status

What is your current citizenship and immigration status?
Canadian citizen Permanent resident (Landed immigrant) Refugee - Permanent resident Refugee - Claimant Temporary Foreign Worker International student Other ______Don’t know Declined to answer
What is your current migrant status?
New to province (within 3 months) Recent immigrant (within 3 years) Recent immigrant and new to province Don’t know Declined to answer Not applicable

Ethnicity

What is your ethnicity?
Caucasian Aboriginal Chinese South Asian African/Caribbean Filipino Latin American Southeast Asian
Arab West Asian Korean Japanese Other ______Don’t know Declined to answer
If Aboriginal ethnicity, which group do you belong to?
First Nations (Status) First Nations (Non Status) Métis Inuit Don’t know Declined to answer Not applicable

Family information

Has your family situation changed since the last follow-up was completed? Yes No Don’t know Declined to answer
Which of the following best describes your current family situation?
Single Couple Single parent family Head of two parent family Other parent of two parent family Other
Don’t know Declined to answer
Are you pregnant? Yes No Don’t know Declined to answer
How many dependents (under 18) do you have? (only include those also enrolled in the program)
Income
What are your current sources of monthly income (before tax)? (Check all that apply and indicate amount)
Aboriginal Funding $______
Alberta Works/Income Support $______
Assured Income for the Severely Handicapped (AISH) $______Binning/Recycling/Bottle Picking $______
Canada Pension Plan Benefits $______
Canada Pension Plan Disability Benefits $______
Child Support/Alimony $______/ Child Tax Credit $______
Employment Insurance (EI) $______
Full-time Employment $______
Guaranteed Income Supplement or Survivor’s Allowance $______
Housing Supplements $______
Long-term Disability (private) $______
Old Age Security Pension (OAS) $______
Other Tax Credits $______
Panhandling $______
Part-time Employment $______/ Retirement pensions, superannuation & annuities$______
Self Employed $______
Student Funding $______
War Veterans Allowance/Veterans Benefits $______
Workers’ Compensation Benefit $______
No Income
Other ______$______
Don’t know
Declined to answer
HEALTH INFORMATION
Have you been diagnosed with any of the following since your last assessment? (Check all that apply)
Physical health issues Mental health issues None Don’t know Declined to answer
Do you have an ongoing mental health condition? Yes - Treated Yes- Untreated Yes- Both treated and untreated No Don’t know Declined to answer
Do you have an ongoing physical health condition? Yes - Treated Yes- Untreated Yes- Both treated and untreated No Don’t know Declined to answer
Do you have an addictions/substance abuse issue? Yes - Treated Yes- Untreated Yes- Both treated and untreated No Don’t know Declined to answer
Do you have Fetal Alcohol Spectrum Disorder (FASD)? Yes – Client suspected Yes- Diagnosed No
Don’t know Declined to answer
Have you had any involvement with the health system since your last assessment?
Yes No Don’t know Declined to answer
Basic needs ASSISTANCE
What basic needs assistance have you received since your last assessment?
Child care Clothing Debt reduction Disability support Employment training Food Furniture
Housing supplement Identification Medication Rent arrears Rent shortfall/subsidy Security deposit
Tenant insurance support Transportation Utility arrears None Other ______Don’t know Declined to answer

SERVICE REFERRALS

What service referrals have you received during the last 3 months?
Aboriginal agencies Addictions service Child support service Counseling Financial service
Health service (non-hospital) Hospital Immigrant serving agencies Legal service Police service None Other ______Don’t know Declined to answer

Justice and legal INFORMATION

Have you had any involvement with the police or the legal system since your last assessment?
Yes No Don’t know Declined to answer

discharge planning

What ongoing supports do you currently require? (Check all that apply)
Ongoing rental supplement No further rental support Mental health support services Addictions/substance abuse support services Physical health support services Household maintenance support services No further support services Other ______Don’t know Declined to answer

client Satisfaction

Please rate your overall satisfaction with the program you participated in:
Very satisfied Satisfied Neither satisfied nor dissatisfied Dissatisfied Very Dissatisfied Don’t know
Declined to answer
Please rate to what extent you agree or disagree with the following statements:
The support services provided to me through the program was appropriate and met my personal needs
Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Don’t know Declined to answer
The support services I received from my case worker were appropriate and met my personal needs
Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Don’t know Declined to answer
Through the program, I was provided with assistance to connect with the government services that I required
Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Don’t know Declined to answer

NOTES:

Support Services Exit Assessment - Page 1 of 3

Updated 7/27/2015